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Erectile dysfunction Assessment

Health Screening

Please answer the following questions to help us determine if this service is appropriate for you.

Erectile Dysfunction Assessment

Are you male and aged between 18–75?*

Do you smoke or drink?*

Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects?*

Do you have trouble achieving or maintaining your erection?*

In the past 6 months, how often do you have difficulty getting and/or sustaining an erection during sexual activity?*

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?*

If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Do you have low blood pressure (below 90/50)?*

If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Have you been advised to avoid strenuous exercise?*

Would you have any difficulty walking at a fast pace for 5 minutes?*

Do you suffer from depression for which you have not seen a GP?*

Do you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously?*

Have you ever suffered from any of the following problems?*

Heart problems, stroke, sight loss (NAION), blood disorders, ulcers, liver/kidney problems, prolonged erections, penile conditions, retinitis pigmentosa, multiple myeloma, galactose intolerance, or serious medical conditions.

Are you taking any medicines known as nitrates or nitric oxide donors ('poppers')?*

Includes glyceryl trinitrate, isosorbide mononitrate, sprays, tablets, patches. Often taken for angina.

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?*

Are you taking any of the following medications?*

ED meds (excluding standard), nitrates, illegal drugs, 'poppers', alpha blockers, BP meds, warfarin, antivirals, nicorandil, antifungals, antiarrhythmics, antibiotics, anticonvulsants, riociguat, rifampicin.

Do you understand that erectile dysfunction can be associated with a number of contributing conditions and agree to speak to your GP within 6 months?*

In the rare event, I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, I agree that I will seek immediate medical assistance.*

Do you agree to the following?*

You will read the leaflet, inform your GP of side effects, use medication only for yourself, and answer all questions truthfully.

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